Effects of Health Plan-Sponsored Fitness Center Benefits on ...

Department <strong>of</strong> Veterans Affairs 

<strong>Health</strong> Services Research & Development Service 

Evidence-based Synthesis Program 

<strong>Effects</strong> <strong>of</strong> <strong>Health</strong> <strong>Plan</strong>-<strong>Sponsored</strong> 

<strong>Fitness</strong> <strong>Center</strong> <strong>Benefits</strong> on Physical 

Activity, <strong>Health</strong> Outcomes, and <strong>Health</strong> 

Care Costs and Utilization: 

A Systematic Review 

EXECUTIVE SUMMARY 

October 2012 

Prepared for: 


Veterans <strong>Health</strong> Administration 

Quality Enhancement Research Initiative 

<strong>Health</strong> Services Research & Development Service 

Washington, DC 20420 

Prepared by: 

Evidence-based Synthesis Program (ESP) <strong>Center</strong> 

Durham VA Medical <strong>Center</strong> 

Durham, NC 

John W Williams Jr., M.D., M.H.Sc., Director 

Investigators: 

Co-Principal Investigators: 

Heather A. King, Ph.D. 

Jennifer M. Gierisch, Ph.D., M.P.H. 

Co-Investigators: 

John W. Williams Jr., M.D., M.H.Sc. 

Matthew L. Maciejewski, Ph.D. 

Research Associate: 

Avishek Nagi, M.S. 

Medical Editor: 

Liz Wing, M.A.

<strong>Effects</strong> <strong>of</strong> <strong>Health</strong> <strong>Plan</strong>-<strong>Sponsored</strong> <strong>Fitness</strong> <strong>Center</strong> <strong>Benefits</strong> 


PREFACE 

Quality Enhancement Research Initiative’s (QUERI’s) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses <strong>of</strong> targeted healthcare topics 

<strong>of</strong> particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare <strong>of</strong> Veterans. The ESP disseminates these reports throughout 

VA. 

QUERI provides funding for four ESP <strong>Center</strong>s and each <strong>Center</strong> has an active VA affiliation. The 

ESP <strong>Center</strong>s generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• guide the implementation <strong>of</strong> effective services to improve patient outcomes and to 

support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge. 

In 2009, the ESP Coordinating <strong>Center</strong> was created to expand the capacity <strong>of</strong> QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the <strong>Center</strong> established a Steering Committee comprised <strong>of</strong> QUERI field-based investigators, 

VA Patient Care Services, Office <strong>of</strong> Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics <strong>of</strong> importance to Veterans and the 

VA healthcare system. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating <strong>Center</strong> Program Manager, at nicole.floyd@va.gov. 

Recommended citation: King HA, Gierisch JM, Williams JW Jr, Maciejewski ML. <strong>Effects</strong> <strong>of</strong> 

<strong>Health</strong> <strong>Plan</strong>-<strong>Sponsored</strong> <strong>Fitness</strong> <strong>Center</strong> <strong>Benefits</strong> on Physical Activity, <strong>Health</strong> Outcomes, and 

<strong>Health</strong> Care Costs and Utilization: A Systematic Review. VA-ESP Project #09-010; 2012. 

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) <strong>Center</strong> located at the Durham VA Medical <strong>Center</strong>, Durham, NC, funded by the 

Department <strong>of</strong> Veterans Affairs, Veterans <strong>Health</strong> Administration, Office <strong>of</strong> Research 

and Development, <strong>Health</strong> Services Research and Development. The findings and 

conclusions in this document are those <strong>of</strong> the author(s) who are responsible for its 

contents; the findings and conclusions do not necessarily represent the views <strong>of</strong> 

the Department <strong>of</strong> Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an <strong>of</strong>ficial position <strong>of</strong> the Department 

<strong>of</strong> Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that con¬flict with material presented 

in the report. 

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EXECUTIVE SUMMARY 

BACKGROUND 

Regular physical activity has many positive health benefits, including protection against chronic 

disease, improved physical and mental health and cognitive function, and better health-related 

related quality <strong>of</strong> life. Moreover, lack <strong>of</strong> physical activity is associated with higher health 

care costs and utilization. Many Americans, however, do not get the recommended levels <strong>of</strong> 

physical activity. For Veterans, Veterans Affairs (VA) health care users are less likely to meet 

physical activity recommendations and more likely to be physically inactive compared with 

Veterans who do not use VA health care. Multiple personal, social, and environmental factors 

influence participation in physical activity. Providing memberships to fitness centers may be 

a viable option to increase physical activity and the positive health outcomes associated with 

such activity. Given that most Americans have access to some form <strong>of</strong> health insurance, health 

plan promotion <strong>of</strong> and coverage for fitness center memberships has the potential to address 

multiple barriers to physical activity (e.g., cost, access) and extend fitness center access to many 

Americans. 

Our objective in this evidence synthesis was to summarize the results <strong>of</strong> diverse studies <strong>of</strong> health 

plan-sponsored fitness center memberships in an effort to understand how these benefits affect 

physical activity, clinical outcomes, health care costs and utilization, retention <strong>of</strong> plan members, 

and member satisfaction. 

Key Question 1. What are the effects <strong>of</strong> policy/benefits packages that include vouchers, rebates, 

premium reductions, or other economic incentives to encourage physical activity through fitness 

center memberships on: 

(a) Physical activity participation rates among plan members? 

(b) <strong>Health</strong> outcomes demonstrated to be improved by physical activity (i.e., weight, pain, 

glucose, blood pressure, health-related quality <strong>of</strong> life)? 

(c) Overall health care costs and health care utilization? 

Key Question 2. What are the effects <strong>of</strong> policy/benefits packages that include vouchers, rebates, 

premium reductions, or other economic incentives to encourage physical activity through fitness 

center memberships on satisfaction with the health plan and retention <strong>of</strong> members in the health 

plan? 

Key Question 3. Do the effects <strong>of</strong> policy/benefits packages to encourage physical activity vary 

by specific characteristics <strong>of</strong> the package (premium vs. lump sum) or age, sex, and physical 

illness <strong>of</strong> participants? 

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METHODS 

In consultation with a master librarian, we searched MEDLINE ® (via PubMed ® ), Embase ® , and 

the Cochrane Database <strong>of</strong> Systematic Reviews for peer-reviewed publications comparing health 

plan-sponsored strategies to encourage physical activity through fitness center memberships 

with standard benefit plans from database inception through January 2012. We selected freetext 

terms to search titles and abstracts as well as validated search terms for both randomized 

controlled trials and relevant observational studies adapted from the Cochrane Effective Practice 

& Organization <strong>of</strong> Care Group search, version 1.9. We limited the search to articles published 

in the English language involving human subjects 18 years <strong>of</strong> age and older. An updated search 

for publications was conducted in May 2012. We also evaluated the bibliographies <strong>of</strong> included 

primary studies. As a mechanism to assess the risk <strong>of</strong> publication bias, we searched www. 

ClinicalTrials.gov for completed but unpublished studies in July 2012. 

DATA SYNTHESIS 

We critically analyzed studies to compare their characteristics, methods, and findings to determine 

the feasibility <strong>of</strong> completing a quantitative synthesis (i.e., meta-analysis) based on the volume <strong>of</strong> 

relevant literature, the completeness <strong>of</strong> the results reported and the conceptual homogeneity <strong>of</strong> the 

studies. As quantitative synthesis was not possible, we analyzed the results qualitatively. 

RATING THE BODY OF EVIDENCE 

In addition to rating the quality <strong>of</strong> individual studies, we evaluated the overall strength <strong>of</strong> 

evidence (SOE) for each Key Question by assessing the following domains: risk <strong>of</strong> bias, 

consistency, directness, precision, strength <strong>of</strong> association (magnitude <strong>of</strong> effect), and publication 

bias. These domains were considered qualitatively, and a summary rating <strong>of</strong> high, moderate, low, 

or insufficient SOE was assigned. 

PEER REVIEW 

A draft version <strong>of</strong> the report was reviewed by technical experts and clinical leadership. A 

transcript <strong>of</strong> their comments can be found in the appendix, which elucidates how each comment 

was considered in the final report. 

RESULTS 

We identified 3584 unique citations from a combined search <strong>of</strong> MEDLINE (via PubMed, 

n=3560), Embase (n=24), and the Cochrane database (n=0). Manual searching <strong>of</strong> included study 

bibliographies and review articles identified 5 additional citations for a total <strong>of</strong> 3589 citations. 

After applying inclusion/exclusion criteria, 4 articles (representing 1 unique study) were included 

in this review. Most studies were excluded because they assessed types <strong>of</strong> physical activity 

promotion strategies other than fitness center memberships (e.g., worksite wellness). Our search 

<strong>of</strong> www.ClinicalTrials.gov did not suggest publication bias. There were no completed studies that 

were unpublished. In addition, there were no ongoing studies on this topic. 

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All articles we identified addressed KQ 1; none addressed KQ 2 or KQ 3 (Table ES-1). The main 

study was a retrospective cohort study rated fair quality that used administrative and claims 

data to assess the health care and utilization effects <strong>of</strong> a health plan-sponsored fitness center 

membership benefit (known as the Silver Sneakers program) among adults 65 years <strong>of</strong> age and 

older who were enrolled in the Group <strong>Health</strong> Cooperative <strong>of</strong> Puget Sound Medicare Advantage 

plan. Two companion articles assessed the effect <strong>of</strong> distance from the fitness center and history <strong>of</strong> 

depression on the uptake <strong>of</strong> fitness center benefits and frequency <strong>of</strong> use among participants. One 

additional companion article assessed the effect <strong>of</strong> this benefit on health care costs and utilization 

among health plan members with diabetes. The Silver Sneakers program assessed in all analyses 

allowed eligible health plan enrollees 65 years <strong>of</strong> age and older to access selected fitness centers 

and all activities (e.g., structured conditioning classes) and facilities (e.g., exercise equipment, 

pool) associated with these fitness centers. The health plan covered the full cost <strong>of</strong> memberships 

for each year; there were no additional costs to the member for the fitness center membership. 

Table ES-1. Overview <strong>of</strong> articles evaluating effects <strong>of</strong> fitness center membership 

Reference Study Details KQ Included Outcomes 

Main study 

Nguyen et al., 

2008 

Group <strong>Health</strong> Cooperative Medicare 

Advantage enrollees ≥ age 65 

Selection dates: Jan 1998–Dec 2003 

Participants: 4766 benefit users 

Matched controls: 9035 benefit nonusers 

Companion articles 

Berke et al., 2006 Group <strong>Health</strong> Cooperative Medicare 



2008 


2008 












Participants: 618 benefit users with diabetes 

Matched controls: 1413 benefit nonusers with 

diabetes 

1a 

1c 

1a 

1a 

1a 

1c 

• Physical activity participation 

• <strong>Health</strong> care cost 

• <strong>Health</strong> care utilization 

Role <strong>of</strong> distance from fitness center on: 

• Uptake <strong>of</strong> benefit 

• Frequency <strong>of</strong> use <strong>of</strong> benefit 

Role <strong>of</strong> depression history on: 

• Uptake <strong>of</strong> benefit 

• Frequency <strong>of</strong> use <strong>of</strong> benefit, risk <strong>of</strong> 

participation lapse 

• Physical activity participation 

• <strong>Health</strong> care cost 

• <strong>Health</strong> care utilization 

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Key Question 1. What are the effects <strong>of</strong> policy/benefits packages that include 

vouchers, rebates, premium reductions, or other economic incentives to 

encourage physical activity through fitness center memberships on: 

(a) Physical activity participation rates among plan members? 

(b) <strong>Health</strong> outcomes demonstrated to be improved by physical activity 

(i.e., weight, pain, glucose, blood pressure, health-related quality <strong>of</strong> life)? 

(c) Overall health care costs and health care utilization? 

KQ 1a: Physical Activity Participation 

None <strong>of</strong> the included articles assessed physical activity as a primary outcome. The only metric <strong>of</strong> 

physical activity was the frequency <strong>of</strong> fitness center visits by participants in the Silver Sneakers 

program such as that reported in the main study and one companion article. Two additional 

companion articles assessed the associations between (1) the distance from the fitness center 

and (2) a history <strong>of</strong> depression on the uptake and frequency <strong>of</strong> use <strong>of</strong> the health plan-sponsored 

fitness center membership benefit. 

In Year 1 <strong>of</strong> the main study, Silver Sneakers participants averaged 75 visits (median 49; 

interquartile range [IQR] 11 to 120). In Year 2, the average number <strong>of</strong> visits declined to 55 

(median 12; IQR 0 to 89). While participation dropped in Year 2, 61 percent <strong>of</strong> participants 

continued to visit fitness centers. A separate analysis using a subset <strong>of</strong> members with diabetes 

from the main study reported similar number <strong>of</strong> average visits per year (72 visits in Year 1, 49 

visits in Year 2). 

Two companion articles provided information on other factors associated with uptake and 

frequency <strong>of</strong> use. Additional analyses suggest that distance from fitness centers and history <strong>of</strong> 

depression influence the uptake <strong>of</strong> health plan-sponsored fitness center memberships. Enrollment 

in a fitness center and frequency <strong>of</strong> use are both associated with distance from gyms. While 

history <strong>of</strong> depression is not associated with participation in a fitness center benefit, health plan 

members with a history <strong>of</strong> depression made fewer visits and were at greater risk <strong>of</strong> lapses in their 

participation compared with nondepressed members. 

KQ 1b: Physical <strong>Health</strong> Outcomes 

No identified studies addressed KQ 1b. 

KQ 1c: <strong>Health</strong> Care Costs and Utilization 

The main study and one companion article reported the effects <strong>of</strong> health plan-sponsored fitness 

center memberships on health care costs and utilization. In adjusted models for Year 1, Nguyen 

et al. reported that adjusted total health care costs were not different between Silver Sneakers 

participants and nonparticipants. By the end <strong>of</strong> Year 2, participants incurred significantly 

lower total health care costs (-$500; CI -$892 to -$106, p=0.01) likely due to fewer inpatient 

admissions and lower inpatient care costs compared with controls. There was evidence <strong>of</strong> a doseresponse 

by average number <strong>of</strong> health club visits. Compared with participants who attended 

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fitness centers less than one time per week, participants who averaged two to less than three or 

three or more visits per week over 2 years had lower adjusted health care costs (2 to



Table ES-2. Evidence gaps and future research 

Evidence Gap Reason Type <strong>of</strong> Studies to Consider 

Patients 

Absence <strong>of</strong> data for patients 

other than those ≥ age 65 

Interventions 

Silver Sneakers program was the 

only benefit assessed 

Outcomes 

Uncertain effects on: 

• Physical activity levels 

• Physical health outcomes 

• <strong>Health</strong> care costs and 

utilization 

Uncertain effects on health plan 

member: 

• Satisfaction 

• Retention 

Abbreviation: RCT = randomized controlled trial 

CONCLUSION 

Insufficient information 




• Multisite cluster RCTs 

• Quasi-experimental studies 

• Prospective cohort studies 

• RCTs <strong>of</strong> head-to-head comparisons <strong>of</strong> different 

types <strong>of</strong> benefit structures 

• Quasi-experimental studies comparing different 

types <strong>of</strong> policy changes that impact benefit 

structures 


• Prospective cohort studies 

• Nonrandomized trials (pre-post designs) 

• Nonrandomized controlled before-and-after studies 


• Prospective or retrospective cohort studies 

• Nonrandomized controlled before-and-after studies 

• Qualitative studies 

<strong>Health</strong> plan-sponsored fitness center memberships have the potential to increase levels <strong>of</strong> physical 

activity and, subsequently, improve health and economic outcomes for Veterans. However, few 

studies have assessed the impact <strong>of</strong> health plan-sponsored fitness membership benefits. The evidence 

base for these claims remains weak due to study design limitations, and insufficient due to the 

paucity <strong>of</strong> literature. The limited evidence provides support for reductions in health care costs and 

utilization when comparing health plan members who choose to participate in health plan-sponsored 

gym memberships with those who do not—but these results may not be generalizable to Veterans 

and are based on study designs that could be subject to bias. The existing literature provides 

little insight into other outcomes such as physical activity, physical health outcomes, or health 

plan member satisfaction or retention. Thus, further evidence is needed on which to base policy 

recommendations on the merits <strong>of</strong> providing health plan-sponsored fitness center memberships. 

ABBREVIATIONS TABLE 

CI 

ES 

IQR 

KQ 

RCT 

SOE 

VA 

confidence interval 

Executive Summary 

interquartile range 

Key Question 

randomized controlled trial 

strength <strong>of</strong> evidence 


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